Evaluation and Management of Anemia in an 89-Year-Old Female with Severe Fatigue
This patient requires endoscopic evaluation of the upper and lower GI tract to rule out gastrointestinal malignancy as the cause of her anemia.
Initial Assessment of Anemia
The patient presents with:
- 89 years of age
- Female
- Severe fatigue for 4 months
- Hemoglobin decrease from 130 to 117 g/L
While this hemoglobin level may not seem severely low, the significant drop (13 g/L) and associated severe fatigue warrant thorough investigation, especially given the patient's advanced age.
Laboratory Workup
First, complete iron studies should be performed to characterize the anemia:
- Serum ferritin
- Transferrin saturation
- Total iron binding capacity
- Serum iron
- Complete blood count with reticulocyte count
- Vitamin B12 and folate levels
- C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
Diagnostic Approach Based on Age and Risk Factors
The British Society of Gastroenterology guidelines strongly recommend that men and postmenopausal women with iron deficiency anemia should undergo endoscopic evaluation of both upper and lower GI tract, even without other GI symptoms 1. This is particularly important because:
- Age, sex, hemoglobin concentration, and mean cell volume are all independent predictors of GI cancer risk in iron deficiency anemia 1
- In patients over 50 years with unexplained iron deficiency anemia, approximately one-third have an underlying bleeding abnormality, and about one-third of these have cancer 1
Endoscopic Evaluation
- Upper endoscopy (gastroscopy): To evaluate for potential sources of blood loss in the upper GI tract
- Colonoscopy: To evaluate the lower GI tract
- For patients not suitable for colonoscopy, CT colonography is a reasonable alternative 1
During gastroscopy, small bowel biopsies should be taken to screen for celiac disease, which is found in 3-5% of cases of iron deficiency anemia 1.
Additional Considerations
Other Potential Causes
While GI malignancy is a significant concern, other causes to consider include:
- Non-GI malignancies
- Anemia of chronic disease
- Nutritional deficiencies
- Medication effects (e.g., NSAIDs, PPIs)
- Chronic kidney disease
Iron Replacement Therapy
While investigating the cause, iron replacement therapy should be initiated:
- Initial therapy: Oral iron supplementation 1
- If oral iron is ineffective, not absorbed, not tolerated, or if anemia is severe: Intravenous iron replacement 1
Assess response after one month (hemoglobin rise of ≥1.0 g/dL, normalization of ferritin and transferrin saturation) 1.
Special Considerations for Elderly Patients
In elderly patients, fatigue from anemia can significantly impact quality of life and functional status. Even mild anemia in this population can contribute to:
- Decreased exercise tolerance
- Cognitive impairment
- Increased risk of falls
- Exacerbation of comorbid conditions, particularly cardiac disease
Follow-up Plan
- Complete iron studies and other laboratory tests
- Schedule endoscopic evaluation (gastroscopy and colonoscopy)
- Begin iron supplementation
- Follow-up within 4 weeks to assess response to iron therapy
- Adjust management based on endoscopic findings and response to iron
Pitfalls to Avoid
- Dismissing mild anemia in elderly patients: Even mild anemia can cause significant symptoms and impact quality of life
- Attributing anemia solely to age: Anemia should never be considered a normal part of aging
- Incomplete evaluation: Failure to investigate the GI tract in elderly patients with new-onset anemia can miss potentially curable malignancies
- Focusing only on iron replacement: While treating the anemia is important, identifying and addressing the underlying cause is crucial
By following this approach, you can ensure thorough evaluation of this elderly patient's anemia while addressing her symptoms and potentially identifying serious underlying conditions that require treatment.